Current through Register Vol. 35, No. 18, September 24, 2024
In addition to the definitions in 59A-46-2 NMSA 1978, the
following terms have the meanings given here.
A.
"Health professional"
includes physicians, dentists, registered nurses, licensed practical nurses,
podiatrists, optometrists, chiropractic physicians, physician assistants,
certified nurse practitioners, certified nurse-midwives, registered lay
midwives, clinical psychologists, social workers, pharmacists, nutritionists,
occupational therapists, physical therapists, and other professionals engaged
in the delivery of health care services who are licensed to practice in New
Mexico, are certified, and are practicing under the authority of an HMO,
medical group, hospital, individual practice association, or other entity
authorized by applicable New Mexico law.
B.
"Individual practice association
(IPA)" means a partnership, association, corporation, or other legal
entity which delivers or arranges for the delivery of health services and which
has entered into written services arrangements with health professionals, a
majority of whom are licensed to practice medicine or osteopathy.
C.
"Medical group" means a
partnership, association, corporation, or other group:
(1) that is composed of health professionals
licensed to practice medicine or osteopathy and of such other licensed health
professionals (including dentists, optometrists, and podiatrists) as are
necessary for the provision of health services for which the group is
responsible;
(2) a majority of the
members of which are licensed to practice medicine or osteopathy; and
(3) the members of which:
(a) after the end of the 48 month period
beginning after the month in which the HMO for which the group provides health
services becomes a qualified HMO, as their principal professional activity
(over 50 percent individually) engage in the coordinated practice of their
profession and as a group responsibility have substantial responsibility (over
35 percent in the aggregate of their professional responsibility) for the
delivery of health services to enrollees of an HMO;
(b) pool their income from practice as
members of the group and distribute it among themselves according to a
prearranged salary or drawing account or other similar plan unrelated to the
provision of specific health services;
(c) share health (including medical) records
and substantial portions of major equipment and of professional, technical, and
administrative staff;
(d) establish
an arrangement whereby an enrollee's enrollment status is not known to the
health professional who provides health services to the enrollee.
D.
"Party-in-interest" means:
(1)
Any director, officer, partner, or employee responsible for management or
administration of an HMO, any person who is directly or indirectly the
beneficial owner of more than 5 percent of the equity of the HMO, any person
who is the beneficial owner of a mortgage, deed of trust, note, or other
interest secured by and valued at more than 5 percent of the assets of the HMO,
and, in the case of an HMO organized as a nonprofit corporation, a founder or
member of the corporation under applicable state corporation law;
(2) Any entity in which a person described in
13 NMAC 10.7.7.4.1 [now Paragraph (1) of Subsection D of 13.10.7.7 NMAC]:
(a) is an officer or director;
(b) is a partner (if the entity is organized
as a partnership);
(c) has directly
or indirectly a beneficial interest of more than 5 percent of the equity;
or
(d) has a mortgage, deed of
trust, note, or other interest valued at more than 5 percent of the assets of
such entity;
(3) Any
spouse, child, or parent of an individual described in 13 NMAC 10.7.7.4.1 [now
Paragraph (1) of Subsection D of 13.10.7.7 NMAC].
E.
"Policy-making body of an
HMO" means a board of directors, board of trustees, executive committee,
governing board, or other body of individuals which has the authority to
establish policy for the HMO.
F.
"Significant business transaction" means any business transaction
or series of transactions during any one fiscal year of the HMO, the total
value of which exceeds the lesser of $25,000 or 5 percent of the total
operating expenses of the HMO.
